Elbow Fractures and Ligament Injuries

RADIUS HEAD FRACTURES

It is the fracture of the bone named radius which is adjacent to the elbow joint. Its connection to the joint makes the treatment of the fracture important. The type of the fracture determines the type of the treatment. According to a classification method, radius head fractures are divided into 4 groups (figure 17).  Type 1 fractures are treated after a 5-7 days of cast treatment by starting an early active rehabilitation. For the other types of fractures, active rehabilitation is implemented after surgical repair and later on (figure 18, figure 19). The aim here is to avoid limitation of movement and instability. Type 4 fractures are usually observed together with other fractures around the elbow (dislocation, ligament injury, other fractures etc.). if the fracture is in too much small pieces to be repaired, these pieces are taken out and a radius head like foreign object (radius head prosthesis) is implanted. The aim here is to prevent the occurrence of instability on the elbow joint. (In the cases where the medial collateral ligament (MCL) laceration of elbow is not noticed and radius head is taken out, instability occurs.) The repair of the accompanying fractures and ligament injuries should be made simultaneously.

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Complications: The most common complication with both surgically or non-surgically treated patients is the limitation of movement. The secondary complications are instability, arthritis on the late period, and wrist pain due to shortness on the radius.

Combination 1-Radius head fracture and MCL (medial collateral ligament) laceration of elbow:

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MCL tends to heal when radius head is repaired. That’s why, the fracture is repaired if possible; and if not, it is changed with prosthesis (figure 19, figure 20). If the medial collateral ligament laceration (MCL) of elbow is passed and the radius head is taken out, instability occurs.

 

Combination 2-Radius head fracture and elbow joint dislocation combination:

The main invariant principle in the treatment is also here. If the coronoid is steady, dislocation is fixed and the range of movement in which the joint is stabile is observed. Radius head fracture is treated according to its type.

 

OLECRANON FRACTURES

The bone process on the posterior side of the joint which we lean our elbow to is called olecranon. According to a classification method, it divides into 6 groups (figure 21). Nondisplaced fractures (type 1) are treated by applying splint for 3 weeks. The splint is taken out once a day and active joint movement is made. Displacement on the fractured pieces is followed by weekly film controls. The splint is taken out on the third week and it is followed up by arm hanger for the following three weeks. Type II, III, IV, V and VI fractures are surgically treated (figure 22, figure 23). Type 5 and type 6 fractures are observed together with other injuries around the elbow (dislocation, ligament injuries, other fractures etc.). The purpose of the treatment is to have a function-preserved and painless elbow.

Complications: dissynostosis, fixation loss (laxation of the nails used to fix the fracture) and arthritis are the probable complications.
 

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CORONOID PROCESS FRACTURES

Coronoid process is an important bone that is not externally visible. It is a small but functionally important piece which prevents the dislocation of the elbow like a hingle and to which the ligaments holding the elbow as a whole.  Unaccompanied coronoid fracture is rarely seen. It is generally observed accompanied by radius head fracture or when the elbow joint is dislocated. According to a classification method, it divides into 4 groups (figure 24). It is a generally accepted approach that type 1 fractures are not treated with surgery while the others are.

Type 1 fractures (figure 25): There is splinter-like piece. It shows that the elbow joint is dislocated and automatically located again. That’s why, there is ligament injury. However, the elbow joint is generally stabile. In many cases, open surgery is not required. After a short term of rest, rehabilitation is started.

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-Type II fractures (figure 26, figure 27): the fracture has nearly 50% of the coronoid. The joint is not stabile, it has the risk of re-dislocation (especially when accompanied by radius head fractures). Surgical treatment is the most appropriate way. If the radius head is fracture, the lateral method is applied; if not, the approach shall be medial (figure 28, figure 29). According to the dimension of the fracture, fixation shall be made either by nail or stitch. It is recommended that the fixation is protected by jointed external fixator for 3-6 weeks to balance the dynamic forces applied to the joint.

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-Type III fractures: these are the most difficult injuries to treat. The joint is not stabile, it has the risk of re-dislocation. It is usually observed together with other fractures and ligament injuries (figure 30) If the coronoid is in one piece (type IIIA) then screw fixation can be used. If it is fragmented (type IIIB) the pieces are brought together by suture fixation. In any case, the main purpose is to prevent the displacement of the ulna to the posterior which means the dislocation of the joint.

 

TERRİBLE TRİAD INJURIES: 

It means the compound of radius head fracture, coronoid fracture and elbow dislocation (figure 30). First, the coronoid is repaired. If the olecranon is also fractured, then this approach can be used to reach to the coronoid. If not, lateral approach is preferred and coronoid is fixed before the radius head. Then, radius head is restored (figure 31). LUCL should certainly be repaired. External fixator can be used after all the fixations. In such elbow joint injuries, joint range of motion and stability can be signifacantly preserved by an early and appropriate surgical repair (figure 32, figure 33). The most probable complications during the surgery are nerve / vein injuries, disunion, infection, more limited joint movements (especially with an inappropriate radius head prosthesis) and joint instability (figure 34, figure 35, figure 36, figure 37, figure 38, figure 39, figure 40, figure 41).

 

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HUMERUS LOWER END FRACTURES (ADJACENT TO ELBOW JOINT)

One third of the humerus fractures is the humerus lower end fractures. The purpose in the treatment is to preserve the elbow joint movements in the functional space and without any pain as usual. The radius and ulna which composes a joint together with the unique anatomy of humerus creates a  complicated classification with 27 fracture types and subgroups. Therefore it is difficult to explain the classification here. In summary, the more the fracture gets closer to the joint and includes pieces, the more difficult to make surgery and rehabilitation after the surgery (figure 42, figure 43). It is also an indication for the unexpected process of the treatment in such fractures.

Surgical repair is the most logical option for the most humerus lower end fractures of the adults. The purpose of the treatment is to have a stable, painless and functional elbow joint (figure 44, figure 45). Previously mentioned complications are also possible with the surgical treatment of such fractures.

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CAPITELLUM FRACTURES

Capitellum is an intraarticular structure. It is an important part of the bone called humerus extending intraarticularly (figure 46). The fracture may be connected with other injuries like radius head fracture or elbow dislocation. The injury is difficult to repair as it occurs on the coronal plan (figure 47). Stable fixation and early movement decreases the avascular necrosis risk and helps to regain the joint movements.

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HORİİ CIRCLE INJURY

The information on the isolated injuries of the ligaments holding the elbow joint together ia aforementioned. Sometimes, the energy of the power applied to the elbow joint is too much to rupture all the ligaments and capsule from one side to another (figure 48). In summary, the rupture of all the ligaments and capsule holding the elbow together is called Horri injury (figure 49). The ecchymosis  and hematoma on the  medial and lateral part of the elbow joint is another significant finding on the physical examination after the injury (figure 50 and figure 51). The treatment of such injuries is to perform surgical repair and start early rehabilitation (figure 52, figure 53, figure 54, figure 55). The previously mentioned complications are also possible for the surgical treatment of such fractures.

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